General Surgery Coding Alert

Beware gastric restrictive procedure bundles, too.

Already hemmed in by prior Correct Coding Initiative (CCI) edits, you'll find even fewer times you can report fine needle aspiration (FNA) with other surgical procedures, based on third quarter changes.

CCI version 17.2, which takes effect July 1, offers 2,367 new edit pairs and deletes 336 bundles, according to an analysis by Frank Cohen, MPA, MBB, principal and senior analyst with The Frank Cohen Group, LLC. The majority of edits impact codes from the musculoskeletal code range (20000-29999), but you'll find new bundles for codes throughout the CPT® manual.

Nix FNA With Soft Tissue Tumor Codes

Although CCI previously appeared to do a thorough job of bundling FNA codes 10021-10022 (Fine needle aspiration; ...) into most biopsy, excision, and resection codes, the new version of CCI takes it a step further.

Effective July 1, you'll find 10021-10022 bundled with scores of additional codes for subcutaneous/subfascial soft tissue tumor excision and radical resection. CPT® organizes the soft-tissue tumor codes by body site, scattered throughout the musculoskeletal surgery section from head (21011-21016, Excision/radical resection, tumor, soft tissue of face or scalp ...) to toe (28039-28047, Excision/radical resection, tumor, soft tissue of foot or toe ...).

"Although CCI already paired many of these services, version 17.2 comes back and fills the gap so that FNA is bundled with all the soft tissue tumor excision and resection codes," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, manager of compliance education for the University of Washington Physicians Compliance Program in Seattle.

Here's why: CMS bundles FNA and soft tissue tumor codes under the "sequential procedures" policy. The guidance states, "On occasions where it is necessary that the same provider attempts several procedures in direct succession at a patient encounter to accomplish the same end, only the procedure that successfully accomplishes the expected result is reported." Listing FNA as a column 2 code indicates that you should not separately bill an FNA when the surgeon follows with another soft tissue tumor excision or resection procedure at the same site.

Exception: "If the surgeon documents that the FNA and the soft tissue tumor procedure were for separate sites, you can code both services," Bucknam says. In that case, you would need to override the CCI edit pair by appending a modifier such as 59 (Distinct procedural service) to the FNA code.

Choose Most Extensive Procedure for Gastric Restriction

CCI 17.2 adds 10 edit pairs for 43775 (Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy [i.e., sleeve gastrectomy]). You'll find 43775 as a column 1 code for its parent code 43770 (... placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components) and as a column 2 code for other gastric restriction procedures 43843-43847 (Gastric, restrictive procedure ...). You shouldn't find those bundles a problem for your practice -- simply report the single most descriptive code for the gastric restrictive procedure your surgeon performs.

Recall 'separate procedures:' CCI 17.2 also bundles 43775 as the column 1 code for the following "separate procedures:"

• 43653 -- Laparoscopy, surgical; gastrostomy, without construction of gastric tube (e.g., Stamm procedure) (separate procedure)
• 44005 -- Enterolysis (freeing of intestinal adhesion) (separate procedure)
• 44180 -- Laparoscopy, surgical, enterolysis (freeing of intestinal adhesion) (separate procedure)
• 58660 -- Laparoscopy, surgical; with lysis of adhesions (salpingolysis, ovariolysis) (separate procedure).

AV Shunt Includes Vessel Repair

When your surgeon places an arteriovenous (AV) shunt, 36147 (Introduction of needle and/or catheter, arteriovenous shunt created for dialysis [graft/fistula]; initial access with complete radiological evaluation of dialysis access, including fluoroscopy, image documentation and report [includes access of shunt, injection[s] of contrast, and all necessary imaging from the arterial anastomosis and adjacent artery through entire venous outflow including the inferior or superior vena cava]) includes any vessel repair services, according to CCI 17.2 The latest edits list the following codes in column 2 with 36147:

• 35206 -- Repair blood vessel, direct; upper extremity
• 35226 -- ... lower extremity
• 35236 -- Repair blood vessel with vein graft; upper extremity
• 35256 -- ... lower extremity
• 35266 -- Repair blood vessel with graft other than vein; upper extremity
• 35286 -- ... lower extremity.

That means you should bundle any vessel repair that your surgeon performs as part of the AV shunt placement.

On the other hand: "If the surgeon performs a separate repair on a distinct blood vessel that isn't part of the AV shunt procedure, you can separately report the appropriate code, such as 35206, by appending modifier 59 (Distinct procedural service)," says Lynn Woolard, practice manager with General and Vascular Surgery, Ltd., in Elgin, Ill.

Hemorrhoidectomy -- Don't Unbundle Scope

When your surgeon performs an internal hemorrhoid ligation (46221, Hemorrhoidectomy, internal, by rubber band ligation[s]), the proctosigmoidoscopy, sigmoidoscopy, or anoscopy is included, according to CCI 17.2. That's why you'll see new 46221 edit pairs with the following codes in column 2:

• 45300 -- Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
• 45303 -- ... with dilation (e.g., balloon, guide wire, bougie)
• 45317 -- ...with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
• 45330 -- Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
• 45334 -- ... with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
• 45340 -- ... with dilation by balloon, 1 or more strictures
• 46614 -- Anoscopy; with control of bleeding (e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator).